The Baltimore Capitation Project

Recipient of:

1. General Description:

In 1986, the Baltimore City Health Department (BCHD) received a five-year grant from the Robert Wood Johnson Foundation (RWJ) Program on Chronic Mental Illness. The grant established Baltimore Mental Health Systems, Inc. (BMHS), as the local mental health authority for Baltimore City. BMHS is a public nonprofit entity, which maintains an accountability to government. BMHS' focus has been on expanding the range of services, improving continuity of care, developing new affordable housing opportunities, creating new financing initiatives, and promoting community acceptance and public education.

BMHS is the manager, funder and coordinator for public mental health services in Baltimore City. BMHS is not a direct service provider. Mental health services are provided by a network of nonprofit agencies and private practitioners. In fiscal year 2000 (July 1, 1999 to June 30, 2000) approximately 24,000 Baltimore City residents received services through the Public Mental Health System (PMHS).

BMHS' Mission and Philosophy Statement

The mission of BMHS is to develop and manage a system of care in which all Baltimore City residents have access to high quality public mental health services. Services will be designed to meet the needs of the community, based on input received during ongoing planning processes. Baltimore Mental Health Systems, Inc. (BMHS) will be viewed as a model for other local mental health authorities throughout the country because of effective leadership in the community, efficient management of costs, and a comprehensive data-driven quality management program.

Accomplishments

Over the past fifteen years, BMHS has been very successful in developing a system of care for adults with serious and persistent mental illness and children with serious emotional problems. The accomplishments include but are not limited to the following:

A. Developed a range of citywide crisis services.

B. Created a Mental Health Information System (MHIS) which serves as a management, administrative, and billing tool that has been very valuable to mental health providers.

C. Developed affordable housing through the efforts of its housing nonprofit Community Housing Associates, Inc. (CHA). CHA has spurred the development of affordable housing in Baltimore City for more than 600 adults with mental illness through various programs.

D. Over the past eight years, BMHS has expanded the range of services to individuals who have a serious mental illness and are homeless or at great risk of becoming homeless.

E. In collaboration with the Baltimore City Public Schools, Office of Economic Development and Baltimore City Health Department, BMHS funds, manages, and coordinates mental health services in 80 of the city's 180 schools.

F. Developed and implemented an innovative mental health capitation program which provides innovative flexible services to individuals with serious and persistent mental illness.

BMHS's application for the Thomas M. Wernert award for Innovation in Community Behavioral Healthcare 2001 is for its innovative mental health capitation program.

Baltimore Capitation Project Description:

In early 1993, Baltimore Mental Health Systems, Inc. established a planning group comprised of BMHS staff, mental health financing specialists, the State of Maryland's Mental Hygiene Administration (MHA), and the State Medicaid Agency to address the needs of individuals with serious and persistent mental illness who have not been well served by the community-based public mental health system. The most severely ill of these individuals typically have unstable housing, frequent hospitalizations and/or extended stays at State hospitals, poor access to medical care, social isolation, poor psycho-social functioning, and many have serious substance use disorders. Traditional service systems have been unable to provide services necessary to help stabilize these individuals and improve their quality of life. To address this, the work group proposed the development of a specialized mental health partial capitation demonstration project which would have a single point of accountability and responsibility for the individual, a single rate of payment per patient that would integrate State general funds and Medicaid dollars, have well defined performance outcomes, encourage flexible individualized services, have built-in incentives, and target 300 individuals most in need.

The purpose of the mental health capitation project is to remove categorical funding barriers to facilitate high quality comprehensive care to clients in the community with individualized, flexible and innovative treatment plans. Specific goals of the project are: enhanced community treatment and quality of care; improved quality of life measured by improved outcomes; efficient use of resources to support the best clinical care; increase the continuum of services, including services that are useful but not easily paid for under current funding; and reduction of use of expensive psychiatric bed days with provision of appropriate individualized community services.

The program was implemented in late 1993 with the selection of two Baltimore City mental health providers: the North Baltimore Center (Chesapeake Connections) and Johns Hopkins Bayview Medical Center (Creative Alternatives), to serve as the mental health capitation providers. The programs are now in their seventh year of continuous service, with 277 members enrolled and receiving services. The original five year demonstration project has ended, and the program has been continued with possible expansion beyond the original goal of 300 enrollees. The first modest expansion has already been approved by the State, with a total of 310 enrollees funded for fiscal year 2001. The first group of enrollees in the project were drawn from the State hospital population: admission criteria for these individuals was hospitalization for more than six consecutive months, but most of them had been in the hospital on average more than six years prior to enrollment in capitation. Some of them had been institutionalized 10 or 20 years and most continued to display significant psychotic symptoms and poor overall functioning. The Baltimore programs took on the ambitious task of bringing institutionalized people entrenched in the State hospital world out into community placements in Baltimore City. This ambitious work continued with the second group who are individuals from the community who have been hospitalized at least four times in the past two years, or have been seen in emergency rooms for psychiatric reasons more than seven times in the past two years.

The programs operate with the slogans "Anything is Possible" and "Whatever it Takes". Enrollees (called "members") are assigned to treatment teams consisting of a psychiatrist, team leader (usually a Master's prepared nurse or social worker), personal service coordinators or case managers (Master's and Bachelor's prepared mental health professionals), and community support staff who are para-professionals and maybe mental health consumers who teach community living skills. Additionally, each program employs specialists in employment, social recreation, housing, entitlements, and substance abuse who work with all the treatment teams and members. Many members are seen daily or even twice daily. The average number of visits per client per month is about 14, and no one is seen less than four times per month.

Team staff including the psychiatrist see members at various locations including the program site, in members' homes, at public meeting places, restaurants, etc. The team also visits members in the hospital when they are hospitalized for medical or psychiatric reasons. Family members are also encouraged to participate, and whenever possible they are included in meetings with members at their homes. Both programs also have social events to which family members are invited and many often attend. Members are expected to be linked to somatic care within 30 days of enrollment, and on an ongoing basis members are seen by somatic care providers an average of 6.6 times per year.

2. How the program incorporates customer orientation, clinical excellence, continuity and stewardship of public funds into ongoing planning, operations, quality improvement and evaluation.

Referrals to the program come from psychiatric hospitals (State, private, and general hospital' psychiatric units) and community providers and are sent to BMHS which serves as the gatekeeper for the program. BMHS staff review referrals to ensure the individual meets the program's criteria and the individual can provide voluntarily consent for enrollment. The referrals are assigned to either program. Once the programs receive the referrals they are responsible for educating the consumer about the program and obtaining informed consent for enrollment. Participation in the program is strictly voluntary and individuals may disenroll at anytime.

The members are actively involved in the development of their service/treatment plans. Traditional treatment planning approaches often set goals and objectives based on clinical outcomes determined by the professional staff, sometimes with minimal input from their patients. What makes the capitation program different is that each member is treated as the driver of his or her treatment. Members are asked what they want and this is included in their service plan. Wants identified may be as simple as getting an air conditioner in their apartment to as complex as going to college or choosing a career. Team staff assist the member in breaking their goals down into smaller tasks that can be realistically achieved, but no goal is treated as impossible. Since funding is flexible, funds are available to pay for goods and services that are not usually covered by the usual funding mechanisms and for which the cost would be prohibitive for members on fixed incomes from entitlements. This allows for funding of education courses, specialized job training, furniture and other personal needs, recreational activities, and other non-traditional items along with the usual mental health services that may be required such as psycho-social rehabilitation, partial hospitalization, psychotherapy, and inpatient treatment.

The project's quality improvement program includes monitoring the program, evaluating its performance, and providing ongoing feedback to the programs to facilitate appropriate adjustments. An integral part of the quality improvement program has been the development of specific client outcomes which are evaluated on an annual basis. They are: 1) The programs' success in enrolling clients; 2) Numbers of clients disenrolled in a year; 3) Voluntary and involuntary disenrollment; 4) Aggregate use of hospital bed days and Emergency Room visits; 5) Aggregate use of jail days;6) Aggregate use of homeless shelters or days of homelessness; 7) Housing acquisition and retention for clients and number of clients who attain and retain independent housing; 8) The number of clients in skill training; 9) The number of clients with jobs; 10) The extent to which the physical health needs of clients are addressed; 11) The timely submission of accurate data reports; 12) The creative use of existing services, including mainstream community services, or the development of new resources; 13) The success of the program in fulfilling client needs identified in client/program agreement and in improving client's score on psychological and functional assessments. This is measured by random review of a sample of 50% of individual files each year; and, 14) The involvement of clients and families in planning and policy- making decisions.

Based on the annual evaluation of the outcomes conducted by an independent evaluator, each program receives a grade which determines whether the program will receive incentive funds. The program must score at least a B on the evaluation to earn incentive funds which are used to benefit clients and staff of the capitation program.

A component of the program's annual evaluation is interviews with client and family members to determine satisfaction with the program. Client satisfaction is measured by the independent evaluator's interviews with 50% of the active clients in each program. The majority of the interviews take place in the individual's place of residence. For the past two years, the evaluator has used a formal instrument that measures client satisfaction. Overall, client satisfaction is high for both programs with an over 90% satisfaction score for the six completed years of the program.

Three years ago, the independent evaluator began interviewing family members to gauge their satisfaction of the program. Family member's comments tend to be very positive and include the following statements: "best program ever", "dedicated staff", "less burden on me", "staff takes the time for one on one attention to client's problems", "my stress has been relieved", and "most comprehensive program-he has the right medication and they make sure he takes it." The client and family satisfaction information provides valuable information which the programs incorporate into their quality improvement programs.

In addition, mechanisms are in place to ensure timely identification and response to critical issues. BMHS employs a part-time Medical Director to oversee the clinical issues of the program. Before a prospective client is referred for admission, the Medical Director convenes a screening committee which includes a physician certified in Internal Medicine to review the clinical history and identify issues that may put the client at risk including medical and psychiatric problems as well as substance abuse and psycho-social issues. Suggestions are made to the programs and follow-up is often requested.

On a weekly basis, reports are sent to the Medical Director about enrolled clients who are at high risk for complications from their medical, psychiatric, housing, or substance use issues or from violence to themselves or others. Feedback and monitoring are provided and there is a regular interchange between program staff and the Medical Director to assure that all possible interventions have been considered. In cases of negative outcome such as client death or disenrollment from the program, the Medical Director reviews the case carefully and makes recommendations for improvements to the programs or suggests interventions that may help avoid a negative outcome.

BMHS staff also arrange training and conferences for program staff about "hot button" topics affecting the client population, including meetings set up to discuss conditional release from hospitals and forensic facilities, housing issues, dually diagnosed clients with psychiatric illnesses and substance abuse, and discussions about informed consent and competency. The programs have frequent opportunities to request training or information about issues they are concerned about, and the programs meet with the Medical Director regularly to share information and raise concerns.

Overall, the Medical Director assists the clinicians in both programs to maintain excellence in their programs and acts as a liaison between regulatory agencies and the clinical programs to facilitate communication and quality care.

3. Program Effectiveness:

During the first six years of the project 100% of the individuals acquired or had housing at the time of enrollment into the program. By the end of the sixth year over 50% of the individuals had obtained independent housing with over 90% of the individuals retaining their independent living situation. This is housing in which the program participant holds the lease and the programs provide intensive supportive services. For some individuals, this means daily visits from the programs. By the end of the sixth year over 60% of the individuals were involved in some type of competitive employment during the year. This is more than double the program's experience during the first year of the project. By emphasizing employment and providing the necessary supports, the programs have been able to make great strides in helping their clients obtain jobs. Both of the programs spend a great deal of time coordinating the medical care of the program participants. One of the programs has hired a nurse practitioner to serve as a medical case manager. By the end of the sixth year, 100% of all enrollees are linked to somatic care. There has been very little use of psychiatric emergency rooms (less than on average .5 visit per enrollee/year), low use of psychiatric hospitals (less than 3.5 days per enrollee/year), low incarceration rates (less than 2 days per enrollee/year), and low homelessness (less than .25 days per enrollee/year).

The best way to describe the success of the program is directly from program participants.

Bernard wrote: "Creative Alternatives made me see more. I never thought I could make it on the street. Creative Alternatives came to the hospital, and I thought I'd take a chance. So far I've been out here for 3 years.....Now I got my own place. I got my own key for my own door. I ride the bus - which I never thought I could do. I've even talked to other people in Washington D.C. about our program.... The doctors didn't think I'd make it, but Creative Alternatives said I would. They believed in me. Look where I am now. I've bus trained people, helped move people to new homes, taken people to get their labs done. Nobody ever trusted me this much. They gave me something to believe."

"My name is Garry and I am an addict. In 1997 I came to the end of my active and day to day use of drugs and alcohol. In the course of my life from the age of six I have suffered from the use of drugs and alcohol along with spending many of my days either in a mental institution, detox, or recovery treatment centers. I hope the word God doesn't offend, but that's the only way I can explain how a woman could walk through the gates of hell and help to free me from them. I first heard of the program a couple of years before I got here when this lady came to my home to talk with me. I lived in an apartment with a bunch of broken t.v.'s, and my wife had left me for the hundredth time because of my addiction to cocaine. I can't remember what was said to me, but a couple of years later I came to the program and my life would never be the same. To tell you what the program has done for me would take a lifetime." Garry has since "graduated" from the capitation program and has gone on to full-time employment as a substance abuse counselor at another agency.

Like the benefits, there are many challenges involved in operating this project. First, the clients have exhibited a very high degree of serious, physical illness necessitating a great deal of time and effort being spent on improving linkages to health care. Second, when greater flexibility and risk-taking are encouraged, it is necessary to constantly balance reasonable risk with high support and prudent oversight. There are also many issues related to housing such as safety, affordability, cleanliness, client choice and whether to enforce minimum guidelines.

Yet, with all of these challenges, the project has been successful as the outcomes indicate. All staff work at developing unique relationships and challenging themselves and their clients to reach their full potential.

4. Replication of the Program:

In this era of managed and rationing of care, BMHS' Baltimore Capitation Project is a specially designed mental health managed care alternative that has been successful in meeting the needs of individuals who have not been well served by the public mental health system. Our model establishes an administrative, clinical and financial framework which we believe can be replicated. We also feel that if another site is unable to adopt the total model some of the component parts lend themselves to replication. The essential components of the project are: single stream funding; individualized services; single point of accountability and responsibility; well-defined outcomes including an aggressive employment and independent housing program; incentives for good performance; well integrated quality improvement program including an annual evaluation; and, ongoing training.

Washington, D.C. and Des Moines, Iowa have developed initiatives that are based on the Baltimore Capitation Project. Staff from these sites have visited our program, met with staff and consumers and have incorporated many aspects of this initiative into their projects. BMHS is committed to continuing to share information and is easily accessible to any site who would like to learn more about organizing, financing and providing services to individuals with complex service needs.

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